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Medical Spa | Houston, TX
Medical Spa | Houston, TX
(281) 810-9083
281-810-9083
  • Home
  • About
    • Medical Spa Blog
    • Patient Forms
    • Payment Options
    • Rewards Program
    • Treatment For Men
  • Facial Services
    • Botox Cosmetic
    • Double Chin
    • Dermal Fillers
      • Juvederm
      • Juvederm Volbella
      • Juvederm Vollure
      • Juvederm Voluma XC
      • Radiesse
      • Restylane
    • Fraxel Laser
    • Ulthera Lift
    • Laser Hair Removal
    • Lip Augmentation
    • IPL Treatments
    • PDO Thread Lift
    • SkinPen
  • Body Services
    • CoolSculpting
    • Laser Hair Removal
    • IPL Treatments
    • 3D Skin Rejuvenation
    • Neck Rejuvenation
  • Skin Services
    • Acne Treatment
    • Chemical Peels
      • Vitalize Peel
      • VI Peel
    • Epidermal Leveling
    • IPL Treatments
    • Laser Genesis
    • Microdermabrasion
    • Rosacea
    • Skin Tightening
    • Skin Care Products
      • Factor Five
      • Latisse
      • SkinCeuticals
      • SkinMedica
      • Visia Skin Complexion Analysis
  • Photo Gallery
  • Reviews
  • Contact Us
    • Book Online!
Home » Client Information Form

Client Information Form

Step 1 of 6

16%
Sex*
MM slash DD slash YYYY
Address*
MM slash DD slash YYYY
Dermatologist in the past year?*
How is your general health?*
Smoke*
Alcohol*
Please mark the following conditions or treatments that you have/had or experienced

Allergies

Do you have any known allergies?*
Are you currently having skin treatments?*
Please mark if you have or have you had any of the following in the last 14 days.
Please mark if you are presently experiencing or have experienced in the past.

Home Care

Please circle the skincare products are you currently using at home.

Sun Protection

Do you use a sunscreen?
Mineral Based?
Do you sunbathe, tan in a tanning bed or participate in outdoor activities?
Have you had any direct unprotected sun exposure in the last 10 days?
When exposed to the sun do you?
What skin conditions do you want to improve?

Body Contouring

Have you had surgical or non-surgical body contouring before?

Additional Information

Is there any other necessary information your skincare specialist should know before beginning your treatment?

VIDEOTAPE AND PHOTOGRAPHS RELEASE AND AUTHORIZATION

hereby irrevocably consent to and authorize the use and reproduction by Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique and its affiliates, or anyone authorized by any of them, of any and all photographs, electronic images or video footage of me taken by Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique, or that Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique has in its possession, provided either by me or by a third party (collectively, Images) for the purpose of informing the medical profession and the general public about plastic surgery and plastic surgery procedures and techniques without compensation to me. Such use shall include, but not be limited to, distributing the Images via print, visual and electronic media, specifically including the Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique website and social media sites such as YouTube, Facebook and Twitter. The Images (including any photographic negatives) shall be the sole property of Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique. I hereby waive any right to inspect or approve the finished product, photograph, video, DVD, CD-ROM or matter that may be used in conjunction therewith or to the eventual use that it might be applied. I hereby release, discharge and agree to hold harmless Vitenas Cosmetic Surgery/ Mirror Mirror Beauty Boutique and its affiliates and their respective representatives, assigns, and employees, and any person acting under their permission or authority, from and against any claims whatsoever in connection with the use of my Images and the reproduction thereof as stated above, including any claim for payment in connection with distribution or publication of the video and/or photographs.

I hereby warrant that I am over twenty-one years of age, and competent to contract in my own name insofar as the above is concerned.

I have read and understand the foregoing release, authorization and agreement, before signing my name below, and enter into it knowingly and voluntarily.

MM slash DD slash YYYY

I have read the above Release and Authorization.

, a minor. I am authorized to sign this authorization on his/her behalf and I give this authorization in the interest of public education.

MM slash DD slash YYYY

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

have received a copy of this office’s Notice of Privacy Practices.

MM slash DD slash YYYY

CANCELLATION AND RESCHEDULING POLICY

Mirror Mirror Beauty Boutique has a 24-hour cancellation and rescheduling policy for consultations. If you cancel or reschedule your consultation appointment with less than a 24-hour notice or fail to be here for your appointment, $100 will be charged to the credit card on file.

Mirror Mirror Beauty Boutique’s cancellation policy exists out of respect for the patients as well as our providers. Cancellations with less than 24-hour notice do not allow other patients the opportunity to schedule an appointment during that time.

A 25% non-refundable deposit is required in order to schedule a treatment. We require a notification of at least 48 hours in order to reschedule your treatment appointment at no cost. If your appointment is cancelled within 48 hours or you arrive more than 30 minutes late to a treatment, the 25% deposit will be forfeited. Treatment fees are payable in full on the first scheduled date of service.

By signing below, you acknowledge that you have read and understand the cancellation/rescheduling policy for Mirror Mirror Beauty Boutique as described above.

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I also understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. I hereby release Mirror Mirror Beauty Boutique from any liability pertaining to treatments, understanding that results cannot be guaranteed due to individual skin and body type(s) and condition(s).

MM slash DD slash YYYY
MM slash DD slash YYYY

Facility Proper Practices

Children

In order to ensure the safety of children and the enjoyment of all guests, we ask that parents or guardians make other arrangements for children, as we cannot accommodate them during your visit. This allows everyone involved in the appointment to give you the attention you deserve.

Pets

Only Working Service Dogs Permitted

the health and safety of our patients, Mirror Mirror Beauty Boutique has a No-Pets policy.
Although we love animals, we ask that you please leave your pet at home during your visit.

This No-Pets policy applies to:

  • Pets
  • Emotional Support Animals
  • Comfort Animals
  • Therapy Animals

Mirror Mirror complies with the Americans with Disabilities Act (ADA) allowing access for all individuals to public places; therefore, we do allow working service dogs to accompany our patients.

Dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA. The Department of Justice has stated that emotional support animals are not protected as service animals under these regulations.

Should you arrive to an appointment with a pet that is not a service animal, you will be asked to reschedule your appointment. To avoid any disruption or inconvenience, we ask that you please leave your pet at home.

Thank you for your cooperation and consideration of all our patients.

MM slash DD slash YYYY
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

*Client testimonials are based on personal experience. Individual results may vary.
Mirror Mirror Beauty Boutique

As Houston’s premier Beauty Boutique, Mirror Mirror is overseen by one of Houston’s Top Board Certified Plastic Surgeons, Paul Vitenas, Jr., M.D., F.A.C.S. Together they are focused on helping you achieve natural looking aesthetic results, in a relaxing spa environment.

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Office Hours

Monday & Friday: 9:00AM - 6:00PM
Saturday: 9:00AM - 5:00PM
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